SPECIAL ARTICLE Almost a tragedy: severe methotrexate toxicity in a hemodialysis patient treated for ectopic pregnancy Nadav Willner & Shimon Storch & Tamar Tadmor & Elad Schiff Received: 9 September 2013 /Accepted: 30 October 2013 /Published online: 26 November 2013 # Springer-Verlag Berlin Heidelberg 2013 Abstract Background Methotrexate (MTX), an antimetabolite of folic acid, is the drug of choice for the nonsurgical management of ectopic pregnancy. MTX-related toxicity may include leuko- penia, thrombocytopenia, pancytopenia, nausea, vomiting, stomatitis, mucositis, and liver and lung toxicity, depending primarily on the dosage of the drug and patients' renal func- tion. Currently, the use of MTX in hemodialysis patients, even at a low dosage, is controversial, and no clear-cut guidelines are available. Case report We report here a rare case of a life-threatening complication characterized by severe pancytopenia and skin and mucosal injury, which developed in a young patient on hemo- dialysis after oral treatment with MTX for ectopic pregnancy. Conclusion We conclude that even low-dose MTX adminis- tration is not to be used in patients with renal insufficiency, and when no other therapeutic options are available we sug- gest taking several clinical measures to prevent or treat myelosuppression. Keywords Ectopic pregnancy . Hemodialysis . Methotrexate toxicity . Mucositis . Myelosuppression Background Methotrexate (MTX) is an antimetabolite of folic acid, used in the treatment of cancer, autoimmune phenomenon and ectopic pregnancies. About 35 % of MTX is bound to plasma proteins and up to 90 % of the absorbed amount is excreted in the urine unchanged within 48 h, mostly within the first 8 h (through glomerular filtration and active tubular secretion) [1]. MTX- related hematological toxicity may include leukopenia, throm- bocytopenia, megaloblastic anemia, and pancytopenia. How- ever, only a few cases of severe pancytopenia caused by low- dose MTX therapy have been reported, and the condition is rarely reported in uremic patients undergoing dialysis therapy [2–5]. To the best of our knowledge, only one reported case of this kind refers to MTX therapy given for the management of ectopic pregnancy [6]. Since MTX is the drug of choice for the pharmacological management of ectopic pregnancy, pregnant patients with varied medical comorbidities may be candidates for treatment. Here, we report a young patient on hemodialysis who developed severe complications characterized by pancy- topenia, diffuse skin desquamation, and severe mucositis after oral treatment with low-dose MTX for ectopic pregnancy. Case report A 21-year-old hemodialysis-dependent patient for the last 9 years because of hypovolemic shock and multiorgan failure at the age of 12 years was admitted to the hospital with a suspected ectopic pregnancy. Diagnosis was supported by absent menses (8 weeks), elevated β-hCG levels between 40 and 80 U/L, and transvaginal ultrasound that demonstrated a N. Willner : E. Schiff Department of Internal Medicine B, Bnai-Zion Hospital, Haifa, Israel S. Storch Head of Nephrology Department and Renal Unit, Bnai-Zion Hospital, Haifa, Israel T. Tadmor Department of Hematology and Hemato-oncology, Bnai-Zion Hospital, Haifa, Israel E. Schiff Department for Complementary/Integrative Medicine, Law and Ethics, International Center for Health, Law and Ethics, University of Haifa, Haifa, Israel N. Willner (*) 79/9 Hatichon Street, Haifa 32293, Israel e-mail: nadav.willner@gmail.com Eur J Clin Pharmacol (2014) 70:261–263 DOI 10.1007/s00228-013-1608-3